Crown Censures taken by HSE since 1 April 1999

HSWA S3(1)

On the evening of the 6th February 2017, a 13-year-old cadet had attended at EMRFCA’s Ulverscroft Road Army Reserve Centre to participate in cadet training. When leaving the site, the IP attempted to squeeze through a gap in an electric gate. As he did so, the gate opened and he became trapped, sustaining serious injuries.

County HQ, Leicestershire

Health and Safety at Work etc Act 1974 Section 2(1)
Health and Safety at Work etc Act 1974 Section 3(1)

This censure arises from an incident pm 28th June 2018 when nine Prison Officers reported that injuries were sustained during a training exercise involving a serial of officers being petrol bombed. The incident occurred during the 8-day Commanders Course at NTRG Hatfield Woodhouse.
HMPPS had failed to adequately recognise the risks involved with the uncontrolled petrol bombing of commanders during training and as a result of this failure to properly identify and mitigate risk, the officers, both employees of HMPPS and others not in their employ suffered burns to their bodies ranging from scalds and minor burns through to extensive burns requiring skin grafts.

NTRG Hatfield Woodhouse, Doncaster

Health and Safety at Work Act 1974 S2, 1

The Ministry of Defence has been issued with a Crown Censure by the Health and Safety Executive after a military diver died during training. On 14th November 2018, 26-year-old Marine Benjamin McQueen was brought back to surface after he became separated from other divers. He was sadly pronounced dead after CPR was performed. He had been involved in a maritime training exercise when the incident occurred in Portland Harbour.

Portland Harbour

Health and Safety at Work Act 1974 S2, 1

Lance Corporal George Partridge, a serving soldier, died whilst taking part in an Army Diver Class 2 training course. The HSE investigation found deficiencies in the design and delivery of Army Diver training such that it cannot be said that the MOD so far as it reasonably practicable provided a safe system of work or instruction and training. While the cause of LCpl Partridge’s death is not certain, it is possible that the one or more of the deficiencies which have been identified may have caused or contributed to his death.

National Diving and Activity Centre, Chepstow, NP16 7LH

Health and Safety At Work Act 1974 s 2 (1)

The injured person was setting up an experimental test facility for the use of hydrogen gas. The hydrogen was being pumped into a vessel with an intended eventual pressure of 700 bar. During filling of the vessel a couple of leaks on the filling hose and the end cap of the vessel had to be repaired. At approximately 500 bar pressure one of the end caps of the vessel blew off. The escaping hydrogen flashed to flame causing burns to the operative on both hands, forearms, face, neck and back of head.

Health and Safety Laboratories

Health and Safety at Work etc. Act 1974 s2 (1)

Leading Engineering Technician (LET) Neal Edmonds died whilst maintaining a lift.

HMS Bulwark whilst alongside at HM Naval Base, Devonport

Health and Safety At Work Act 1974 s2 (1)
Health and Safety At Work Act 1974 s3 (1)

Ranger Michael Maguire, a serving soldier with C Company, 1st Battalion, Royal Irish Regiment, was killed during a live firing tactical training exercise. The investigation found that his death occurred as a result of the failures by the MOD, his employer, to provide a safe system of work which also exposed members of the public, on a nearby beach, to risk.

Castlemartin Ranges, Pembrokeshire

Health and Safety At Work Act 1974 s2 (1)
Health and Safety At Work Act 1974 s3 (1)

Crown Censure of UKBA following fully justified complaint from civil airline contractor transporting ammunition to Doncaster Finningley Airport. Complaint refers to unsafe handling of live Anti - Tank ammunition without relevant risk assessment and training of Personnel. Airport Employees and members of public at risk from explosion.

Robin Hood Airport

Health and Safety at Work etc. Act 1974 Section 2(1) and 3(1)

An agency driver, working for the MoD, was fatally injured by a reversing vehicle. Mr Graham Wood, 55, was crushed between a reversing lorry and a stationary vehicle on the evening of 19 November 2013. The incident occurred when Mr Wood and a colleague were delivering goods to a large holding area in MoD Kineton, Southam, Warwickshire. The HSE investigation found the MoD failed to assess the risks created by the movement of large vehicles and they failed to ensure a safe system of work was in place to identify and control the risks presented by the movement of large vehicles in this area. Following the incident, a safe system of work including marked parking bays, well defined walkways for pedestrians and a one way system has been introduced.

Kineton, Southam, Warwickshire

Health and Safety at Work etc. Act 1974 Section 2(1) and 2(2)

Fusilier Dean Griffiths, 21, received a fatal bullet wound to the neck on 14 September 2011 during a ‘live’ training exercise at Lydd Ranges military firing range in Kent. The exercise involved troops approaching a specially built ‘shoot through’ compound (not designed to capture rounds), that had been created to simulate the type of building the troops would encounter in Afghanistan. Fusilier Griffiths had been shot as he lined up on the other side of the compound wall. The bullet had passed through an incorrectly placed enemy target, through the compound wall and hit Fusilier Griffiths in the neck. He died at the scene. HSE investigators found that operational pressures and resources available for the exercise necessitated two groups to be merged to cope with the lack of resource. The incident could have been prevented by ensuring unused targets were removed from the compound and by introducing a final walk through before each run through by the RCO (Range Conducting Officer) to ensure all targets corresponded to the target plan for the exercise.

Lydd Ranges – Military firing range in Kent

Health and Safety at Work Act 1974: Section 2(1)

Three soldiers died on a training exercise in the Brecon Beacons in July 2013. Reservists Edward Maher, James Dunsby and Craig Roberts fell ill while on a training test march. Lance Corporal Craig Roberts and Trooper Edward Maher died during the exercise, whilst Corporal James Dunsby suffered multiple organ failure (as a result of hyperthermia) and died on 30 July 2013. The HSE investigation found a failure to plan, assess, and manage risks associated with climatic illness during the training. These failings resulted in the deaths of the three men and heat illness suffered by 10 other reservist casualties on the march.

Brecon Beacons

Health and Safety at Work Act 1974: Section 2(2)(c)

Highways Agency Traffic Officer was working as a Traffic Officer at the time, deployed to a vehicle in a live lane. Had successfully removed vehicle to the hard shoulder and was arranging its recovery when he was hit by an out of control vehicle travelling backwards down the motorway. He died on the scene.

The Highways Agency failed to discharge the duty imposed by Section 2(2)(c) of Health & Safety at Work etc. Act 1974 in that they did not provide the necessary supervision of Highways Agency Traffic Officers based out of the Dartford outstation to ensure, so far as is reasonably practicable, the health & safety at work of its employees.

SE Regional Control Centre/The Highways Agency, Fosterdown, Godstone RH9 8BQ

Health and Safety at Work Act 1974: Section 3

Child sustained major injury when he fell through a glass floor panel in Yarmouth Castle which broke when he jumped on it, leaving large sharp pieces of glass. Crown Censure approved for Section 3(1) Health and Safety at Work Act 1974 case.

Historic Buildings and Monuments Commission, Yarmouth Castle, Quay Street, Yarmouth PO41 0PB

Health and Safety at Work Act 1974: Section 2(1)

Mycobacterium bovis is a biological agent that can cause severe human disease and requires a high level of containment to protect workers in laboratory situations. Over a period of more than 2 years the Animal Health and Veterinary Laboratories Agency (AHVLA) laboratory at Starcross (Devon) failed to appropriately inactivate M. bovis in samples that were subsequently sent to the AHVLA laboratory at Weybridge (Surrey) for genetic testing. Employees at Weybridge were put at serious risk because they handled samples potentially containing live bacteria without suitable containment and control measures believing they were inactivated and posed little risk. Failings were identified with respect to the equipment used, training of staff and the Standard Operating Procedures for the work. In addition, AHVLA failed to monitor the effectiveness of the method used to render the material safe, and managers failed to act when concerns were raised by staff. Consequently, AHVLA failed in their duties under section 2(1) of the Health and Safety at Work etc Act as they did not have a safe system of work to ensure that employees were not exposed to this hazardous biological agent.

AHVLA Starcross Regional Laboratory, Teignbridge, Devon

Health and Safety at Work etc Act 1974, Section 3
Health and Safety at Work etc Act 1974, Section 2(1)
Management of Health and Safety at Work Regulations 1999, Regulation 3(1)

This censure arises from the failure of the MOD Army to ensure the safety of a 14 year old female Army Cadet who died on 3 August 2007 when a Rigid boat capsized on Loch Carnan on South Uist, Western Isles. She was trapped under the hull of the upturned boat and unable to escape. She was attending 2^nd Battalion the Highlanders Army Cadet Force annual camp in the Western Isles at which cadets are assessed on their training progress.

Loch Carnan
South Uist
Western Isles

Health & Safety at Work Act 1974, Section 3(1)

Management of Health & Safety at Work Regulations 1999 5(1)

This censure arises from the self-inflicted death of a prisoner on 26th September 2006 at HM Prison Bullingdon due to non-compliance with Section 3(1) of the Health & Safety at Work Act 1974, and Regulation 5(1) of the Management of Health & Safety at Work Regulations 1999.

HM Prison
Bullingdon
Bicester
Oxon
OX25 1WD

Health & Safety at Work Act 1974, Section 3(1)

This censure arises from an incident which involved a pupil falling six metres in an uncontrolled descent from the top of the wall onto a wood gymnasium floor below.

The School, in accepting the censure on behalf of Greenwich Hospital, admitted that “at the time of the accident the risk assessment, written operating procedure, written procedures or records for examination, inspection and maintenance regime relating to climbing activities/climbing wall and related equipment were not suitable or sufficient so as to ensure that risks were reduced to the lowest level reasonable practicable”.

Health & Safety at Work Act 1974, Section 2
Health & Safety at Work Act 1974, Section 3

This censure arises from the failure by DSTL, which is part of the Ministry of Defence, to ensure the safety of its employees who were part of a team carrying out a trial to test energetic or explosive mixtures on 14th August 2002. The incident resulted in the tragic death of Mr Terry Jupp.

DTSL failed to have a safe system of work in place for the handling and preparation of charges of energetic or explosive mixtures for testing.

Control of Asbestos at Work Regulations 2002, Section 4 (8) (c)
Control of Asbestos at Work Regulations 2002, Section 6 (1) (a)
Control of Asbestos at Work Regulations 2002, Section 10 (1) (a)

In early 2005 a type 2 asbestos survey was undertaken in a boiler room on the site. The report stated that the “whole room considered contaminated. Further debris presumed present to floor and other surfaces”. It recommended that the asbestos be removed.

The report summary recommended that “access to the area should be restricted until they are decontaminated and that air monitoring is carried out within adjacent areas in order to access airborne fibre levels”.

No action taken on the report until October 2007. During the intervening period, the boiler room was accessed on a routine basis by various personnel without any precautions being taken to prevent exposure.

Health & Safety at Work Act 1974, Section 3

Prisoner tested positive for legionella. Investigation revealed serious failings in hot and cold water management leading to potential exposure to legionella of prisoners and others in the Health Care Unit of Nottingham Prison.

Control of Substances Hazardous to Health Regulations 2002(as amended), Regulations 6, 7(5)(c), 9 and 11

Investigations in October 2007 at the Cefas laboratory in Pakefield Road, Lowestoft, identified failings in the assessment and control of substances hazardous to health for known carcinogenic substances, including a failure to maintain control measures.

Management of Health & Safety at Work Regulations 1999, Section 3 (3)
Health & Safety at Work Act 1974, Section 3 (1)

Second prisoner injured on poorly maintained machinery, where identical accident had occurred 11 days previously, injuring another prisoner. Investigation showed Risk Assessments not known about, effective, or up to date following modicifation of machinery. Safety inspection regime seriously flawed and accident investigation process lacking in important steps, and some steps not followed by employees.

Workplace (Health, Safety and Welfare) Regulation, Section 2 (1)

This censure arises from the tragic death of Corporal Thomas Eirian Rees following the failure by the Ministry of Defence (MOD) to ensure his safety during the unloading of armoured fighting vehicles destined for the Gulf on the 22 May 2003.

Health & Safety at Work Act 1974, Section 2 (1)

This censure is about a failure by the Ministry of Defence on the 1 May 2004 to ensure the safety of Lance Bombadier Robert Wilson when he was crushed between a moving Armoured Fighting Vehicle and another stationary vehicle. He later died of the injuries he sustained as a result of this incident.

Workplace (Health, Safety and Welfare) Regulations 1992, Section 7 (1)
Health & Safety at Work Act 1974, Section 33(1)(c)

Non-compliance with Crown Improvement Notice issued as a result of failure to provide reasonable thermal comfort because ventilation air provided was neither efficiently monitored, nor conditioned, to maintain it between recommended levels of 40% to 70% relative humidity and, that as a consequence of this, and draughts, employees felt cold.

Health & Safety at Work etc Act 1974, section 2
Health & Safety at Work etc Act 1974, section 3
Management of Health & Safety at Work Regulations, regulation 3
Management of Health & Safety at Work Regulations, regulation 5

In relation to a specific Royal Navy equipment procurement project: failure to ensure the health and safety of employees and others, failure to carry out suitable and sufficient risk assessment and failure to make and give effect to such arrangements as are appropriate, having regard to the nature of your activities and the size of your undertaking, for the effective planning, organisation, control, monitoring and review of the preventive and protective measures.

Section 2 (1) Health and Safety at Work etc. Act 1974

Failed to ensure so far as was reasonably practicable, the safety of it's employees, in that the risks of them falling whilst climbing Lockwood's Chimney, during the conduct of Adventurous Training at the Resource Initiative Training Centre Fairbourne, were not adequately controlled.[Fatality]

Section 2 (1) Health and Safety at Work etc. Act 1974

Failed to ensure so far as was reasonably practicable, the safety of employees, including Apprentice Tradesman Kevin Alan Sharman, in that the risks of them drowning whilst caving at Porth-yr-Ogof Cave, and/or similar caving systems, during the conduct of Adventurous Training at Sennybridge, were not adequately controlled.

Section 2(1) Health and Safety at Work etc Act 1974

Failure to ensure the safety at work of all their employees, including a Recruit Marine, during Royal Marine recruit training at Woodbury Common, Devon.

Electricity at Work Regulations 1989: Regulation 14 and Regulation 16
Management of Health and Safety at Work Regulations 1999: Regulation 3

Firstly did fail to implement all suitable precautions namely, implementation of a suitable and sufficient safe system of work encompassing a controlled working area suitable for the practice of live working and provision of adequate information, instruction and training to prevent injury to employees engaged in the instruction of testing techniques within the Vocational Training Domestic Appliance Repair Workshop within HMP Perth and that an employee did suffer and electric shock and burns whilst engaged in live testing of a washing machine motor.

Secondly did fail to ensure that all employees undertaking live electrical work in the form of instruction in live testing were in possession of a suitable level of knowledge and experience or were under such supervision as to adequately prevent danger.

Thirdly did fail to make a suitable and sufficient assessment of the risks to the health and safety of your employees to which they were exposed whist they were at work for the purpose of identifying the measures needed to comply with the requirements of the Management of Health and Safety at Work Regulations in that you did not assess the risk to staff from the instruction of live testing techniques within the Vocational Training Domestic Appliance Repair Workshop within HMP Perth.

Health and Safety at Work Etc Act 1974 S3 (1) and Electricity at Work Regulations 1989 Reg 16

MOD employees were required to make 11000volt switchgear safe for contractors to maintain, but failed to recognise live terminals and failed to lock the shutter in the closed (protective) position. A contract electrician gained access to the live terminals and died as a result of the electrical explosion. Another contractor was injured at the same time. Safety programmes for previous years contained similar errors but they were not detected by the auditing process.

(i) Section 2 (1) The Health and Safety at Work etc. Act 1974
(ii) Regulation 3 (1) (a) Management of Health and Safety at Work Regulations 1999

(i) Failure to ensure the health and safety of its employees during the conduct of military diver training courses.
(ii) Failure to make a suitable and sufficient assessment of the risks associated with military diver training.

Offence 1 Regulation 13(1) of the Workplaces (Health, Safety and Welfare) Regulations 1992
Offence 2 Regulation 5(1) of the Management of Health and Safety at Work Regulations 1999
Offence 3 Regulation 6(1) of the Control of Substances Hazardous to Health Regulations 1999

Offence 1 Failed to ensure that effective measures were taken to prevent a person falling more than 2 metres or being struck by a falling object during work on flat roofs at the prison resulting in serious head injuries to an employee who was hit on the head by a falling concrete block.
Offence 2 Failed to make and give effect to appropriate health and safety management arrangements including for risk assessment, management training and for monitoring and review of performance.
Offence 3 Failed to make a suitable and sufficient assessment of the risks to employees and prisoners from exposure to hazardous substances in connection with work including the use of cleaning chemicals on the wings, use of acids in the boiler house, and exposure to wood dusts and paints in woodworking. Resulting in two prisoners being exposed to chlorine gas.

Section 3(1) Health and Safety at Work etc Act 1974

MOD re-surfaced the road with an unsuitable limestone macadam that became dangerously slippery over time. Two fatal accidents occured in 1997 and 1998, but the road had by then been adopted by the Highway Authority and MOD were no longer responsible for it.

(i) Section 2(1) Health and Safety at Work etc Act 1974

(ii) Section 3(1) Health and Safety at Work etc Act 1974

(iii) Regulation 3(1) a and (b) Management of Health and Safety at Work Regulations 1999

(iv) Regulation 8 of the Control of Asbestos at Work Regulations 1987

Between April 1999 and August 2002. Failure to ensure that employees and others were not exposed to risks to their health and safety from asbestos during and after maintenance work carried out in March 2000 and March 2001 at East Lane House, Runcorn, and failure to carry out a suitable and sufficient risk assessment. Failure to prevent or reduce to the lowest level reasonably practicable, by measures other than respiratory protective equipment, exposure of employees and others to asbestos.

Section 2(1) Health and Safety at Work etc Act 1974

An employee at the Mint, was killed when a 6.5 Ton furnace that fell from an overhead crane during a routine operation struck him. The furnace was not properly located on the crane hook at the start of the operation. A safety device designed to confirm that the hook was fully engaged was not functioning properly at the time of the accident, and employees were not aware of its purpose. The Royal Mint had not conducted a suitable and sufficient risk assessment.

Regulation 5(1) Management of Health and Safety at Work Regulations 1999

Failure to put into place proper arrangements for the monitoring and review of preventative measures. The case arose out of an investigation to an accidental shooting of a soldier with a GPMG (General Purpose Machine Gun) 7.62mm support weapon being used in an improvised firing position.

(i) Section 2(1) Health and Safety at Work etc. Act 1974

Failure to provide employees with such instruction and training as was necessary for them to know the risks to their health and the precautions required to prevent or adequately control exposure to asbestos fibres.

(i) Regulation 5(1) Provision and Use of Work Equipment Regulations 1998

(ii) Regulation 6(2) Provision and Use of Work Equipment Regulations 1998

Failure to maintain spin driers in an efficient state, in efficient working order and in good repair. Failure to ensure that spin driers exposed to conditions causing deterioration liable to result in danger were inspected at suitable intervals.

(i) Section 3(1) Health and Safety at Work etc. Act 1974.

(ii) Regulation 3 (1) (b) Management of Health and Safety at Work Regulations 1992

(iii) Regulation 3 (4) (a) Management of Health and Safety at Work Regulations 1992

Cadet fatally injured when she was run over by a vehicle during a night exercise. Poor planning and risks were not properly identified and controlled.

(i) Section 2(1) Health and Safety at Work etc. Act 1974

Failure to ensure safety of employee engaged in slinging of large containers. Risk of falling. Being a Crown employer prevents prosecution . Crown Censure heard and accepted on 7 October 1999 .

(i) Regulation 7 (1) Control of Substances Hazardous to Health Regulations 1994

(ii) Regulation 12 (1) Control of Substances Hazardous to Health Regulations 1994

Research worker potentially exposed to hazard group 3 pathogen following centrifuge accident. Risks not properly controlled. Failure to adequately instruct and train laboratory staff.